Intrapartal Period Learning Material PDF

MARIANO MARCOS STATE UNIVERSITY College of Health Sciences CHAPTER 4. INTRAPARTAL PERIOD (LABOR PROCESS) This section provides information about the labor process, theories explaining the onset of labor, signs and symptoms of labor and facto...

MARIANO MARCOS STATE UNIVERSITY College of Health Sciences CHAPTER 4. INTRAPARTAL PERIOD (LABOR PROCESS) This section provides information about the labor process, theories explaining the onset of labor, signs and symptoms of labor and factors affecting labor. Also the nursing process overview for woman in labor, that includes the stages of labor, signs and symptoms of labor, mechanism of labor, formulating nursing diagnosis, planning and intervention of client undergoing labor and delivery process. This chapter is divided into four (4) lessons. Each lesson has a time allotment of 3 hours except for lesson 3 with 8 hours. Lesson 1. THEORIES OF LABOR Lesson 2. PRELIMINARY/PRODROMAL SIGNS OF LABOR Lesson 3. COMPONENTS OF LABOR AND DELIVERY Lesson 4. NURSING PROCESS OVERVIEW FOR THE WOMAN in LABOR Lesson 1. THEORIES OF LABORT THEORIES OF LABOR HEO THEORIES OF LABOR RIES In this lesson, you are going to discuss the different Theories of Labor explaining how OF LABOR labor begins. There are numbers of factors known to be responsible for the initiation of spontaneous labor that includes withdrawal of progesterone, an increase in prostaglandins and other complex biochemical markers. Learning Outcomes: After mastering the concepts of this lesson, you must have: 1. Familiarize terms related to Labor and Delivery; 2. Enumerated the different theories of labor; 3. Described each theories explaining the onset of labor; and 4. Identified other factors responsible for the initiation of spontaneous labor. Warm-up-activity: Before you will go on with the learning inputs, let’s test your knowledge and understanding about the different terms related to labor and delivery. Question # 1. What comes to your mind when you hear the word labor and delivery? Question #2. Can you identify at least 1 theory why labor begins? Question #3. Are there other factors that would initiate spontaneous labor? 1|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences LABOR and DELIVERY is the culmination of the childbearing cycle and it is the intense period during which the product of conception is expelled from the uterus. LABOR is the process by which the product of conception (viable fetus, placenta, fetal membrane) are expelled from the uterus via the vagina into the external environment. DELIVERY is the expulsion of the product of conception. DELIVERY is the expulsion of the product of conception. Synonyms for Labor and Delivery namely: Parturition, Accouchment, Travail, Confinement. Other related terms: PARTURIENTS is the woman in labor EUTOCIA is normal labor DYSTOCIA is difficult labor. THEORIES OF LABOR 1. UTERINE STRECTH THEORY Uterus become stretched and pressure increases causing physiologic changes that initiates labor When uterine muscle stretched with fetal growth, they got irritated and contract and empty the content of the uterus any hollow body organ when stretched to capacity will necessarily contract and empty. o The uterine muscle stretches from the increasing size of the fetus, which results in release of PROSTAGLANDINS 2. OXYTOCIN THEORY as pregnancy near terms oxytocin production by PPG increases whole the production of OXYTOCINASE (a hormone that counteract effect of oxytocin) by the placenta decreases. Oxytocin stimulates uterine contractions. labor considered a stressful event stimulates hypothalamus to produce oxytocin from posterior pituitary gland, oxytocin causes contraction of smooth muscle of the body o The fetus presses on the cervix, which stimulates the release of OXYTOCIN from the posterior pituitary. 2|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences o OXYTOCIN stimulation works together with prostaglandins to initiate contraction 3. PROGESTERONE DEPRIVATION THEORY progesterone is the hormone being designed to promote pregnancy believed to inhibit uterine motility since the amount is decreased, uterine contraction occurs when progesterone, the hormone that relaxes uterine musculature, decreases in level, with corresponding increase in estrogen, uterine muscle is stimulate thus labor starts o changes in the ratio of ESTROGEN to PROGESTERONE occurs increasing estrogen in relation to progesterone, which is interpreted as PROGESTERONE withdrawal. 4. PROSTAGLANDIN (Estrogenic, Fetal hormone theory) When pregnancy reaches term, the fetal membrane produces large amount of ARACHIDONIC ACID which is converted by maternal deciduas into prostaglandin, that initiates uterine contractions. During labor the level of arachidonic acid in amniotic fluid is very high resulting in increased production of prostaglandin. arachidonic acid is said to increase prostaglandin synthesis which in turn increases uterine contraction o The fetal membrane begins to produce PROSTAGLANDINS, which stimulates contractions (Bienstock, Fox, & Wallach, 2015) 5. THEORY OF AGING PLACENTA due to the decreased blood supply to the placenta the uterus contracts as placenta mature more and more pressure is exerted at the placental site which is the fundal portion, upper 1/3 resulting to decreased blood supply to the fundus which also happen to the contractile portion of the uterus, thus causing contraction o The placenta reaches a set age, which triggers contractions. Activity 1. Application of the Theories of Labor and Delivery ❖ Reflect and analyze the given situation: A primi gravida mother on her 36-37 weeks pregnancy is asking the OB nurse during her last clinic visit “how can I deliver my baby? As a knowledgeable nurse, how can you explain to her relating to the theories of labor. 3|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Wrap-up-activity: Mothers who given prenatal education and information on how labor begins will be having a better understanding on the occurrence of the labor and delivery process. In this section you have reviewed the Principles of Growth and development. You can use the following questions to help you reflect on what you have covered. 1. What is labor and delivery? 2. How will you differentiate labor from delivery? 3. What are others terms related to labor and delivery? 4. What are the theories of labor onset? 5. How are these theories affects the labor process? 6. What are other factors related to the onset of labor and delivery? Post-Assessment You will be given a quiz for the Lesson 1-2. Please wait for the schedule of the evaluation quiz. Reference: Pillitteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing family. 4|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences LESSON 2. SIGNS OF LABOR A common concern of women as they near the end of pregnancy is how they will know if they are beginning labor. Before labor, a woman often experiences subtle signs that signal labor is imminent. It is important to review these with women during the last trimester of pregnancy so they can more easily recognize beginning signs. Learning Outcomes: After mastering the concepts of this lesson, you must have: 1. Described the prodromal signs of labor. 2. Described the true signs of labor. 3. Determined the causes of signs of labor. 4. Explained the comparison between true and false labor. Warm-up-activity: Let’s have an exercise! Determine the following signs and symptoms of labor if it’s true or false sign. True Signs of Labor False Signs of Labor Contraction increases in frequency, no cervical change intensity and duration and occur at no blood show regular interval discomfort in abdomen may be progressive cervical changes relieved by walking blood show sedation tends to decrease the progressive fetal descent number of contractions A.PRELIMINARY/PRODROMAL SIGNS OF LABOR 1. LIGHTENING – “the baby dropped “- setting/descent of the fetal head into the pelvic brim/true labor 5|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences - Secures approximately 10-14 days Primis – occurs 2 weeks before the onset of labor because of tight abdominal muscles Multis – occur on or before labor onset Figure 18. Before and After Lightening of the Baby. Retrieved from https://www.kopabirth.com/week-38-pregnancy- symptoms-1-cm-dilated-signs-of-labor/ EFFECTS: relief of abdominal tightness/diaphragmatic pressure relief of dyspnea – because of the release of pressure on maternal diaphragm increase in the frequency of urination due to pressure of the bladder by the fetal head increase of vaginal discharge- due to ripening of the cervix shooting pain down the legs – from the pressure of the sciatic nerve increase varicosities and pedal edema due to pressure of the pelvic girdle - decrease venous return (lymphatic system push because of gravid uterus) decrease fundal height because of descent of fetal head to pelvic brim *loss of weight about 2-3 lbs 1-2 days before labor - ↓ progesterone; ↓ fluid retention ENGAGEMENT – is not exactly the same as lightening, the descent of the biparietal plane of the fetal head to a level below that of the pelvic inlet - the descent of the biparietal plane of the fetal head to the level below that of the pelvic inlet widest part of the fetus – the biparietal diameter in a cephalic presentation, the intertrochanteric diameter in breech presentation - in primiparas, engagement may or may not be present at the beginning of labor. A presenting part that is not engaged is said to be “ floating”. one that 6|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences is descending but has not yet reached the ischial spines can be said to be “ dipping”. The degree of engagement is assessed by vaginal & cervical examination. *in a primipara, nonengagement of the head @ the beginning of labor indicates a possible complication such as abnormal presentation or position, abnormality of fetal head, or CPD FIXATION –is the decent of the fetal head to the inlet to a level below that of the pelvic inlet. FLOATING - is when the head is still movable above the pelvic inlet on palpation. 2. INCREASED BRAXTON HICK’S CONTRACTION (3-4 weeks before labor) (primis do not distinguish this from the true labor) Characteristics: irregular, painless contraction false labor contraction they do not dilate the cervix abdominal discomfort (confined in the abdomen) relieved by walking 3. LOSS OF WEIGHT (2-3 lbs one to two weeks before labor) - due to the decreased progesterone leading to the decreased fluid retention *progesterone promotes fluid retention, consequently when progesterone is withdrawn extra fluid acquired during pregnancy due to progesterone effect will be excreted resulting in weight loss 4. INCREASED MATERNAL ENERGY OR ACTIVITY LEVEL due to increased adrenaline/epinephrine secretion to prepare the body for the work ahead – may wake in the morning of labor full of energy in order to prepare the mother for the strenuous work of labor, the adrenal gland secrete large amount of epinephrine or adrenalin about 2 weeks before labor begins. This will make the woman highly energetic and active NURSING CARE: - advice the mother not to use this feeling of well being for doing household chores but to save it for labor and delivery 7|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 5. RIPENING OF THE CERVIX from goodell’s sign – cervix becomes “buttersoft” (like the consistency of an ear lobe) cervix must be soften in order for it to be readily dilatabe internal sign usually seen during IE/pelvic exam 6. RUPTURE OF THE MEMBRANE/BAG OF WATER an occasional sign, woman should be advised to go to the hospital immediately for admission. signified by a gush of steadily trickle of clear fluid from the vagina rupture is caused by the pressure of uterine contraction and dilatation of the cervix Indication: a. labor is inevitable – labor will set in within 24 hours. b. infection can easily set in – since the integrity of the uterus has been destroyed IMPLICATION - aseptic technique should be employed in doing perineal care - doctor do less IE - enema should no longer be given - check for temperature and for signs for infection c. Umbilical cord compression or cord prolapse can occur (especially in breech presentation) NURSING CARE TO SPECIFIC SITUATION: 1. Rupture BOW (in ER or Adm. Room) - put immediately to bed - check for the FHT - should not be allowed to remain in sitting and standing position because it increases compression of the cord 2. In labor room – (woman in labor who claims that the BOW has ruptured) - FHT should be checked 3. LOOP coming from vagina (Cord Compression) - put in trendelenburg position – decreases pressure on the cord 8|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences NOTE: 5 minutes of cord compression can cause CNS damage or even death apply a warm saline – saturated OS on the cord to prevent drying 7. SHOW – pinkish vaginal discharge due to the pressure of the presenting part causes rupture of the minute capillaries - passage of operculum/mucus plug indicate that cervix has started to dilate B. SIGNS OF TRUE LABOR a. UTERINE CONTRACTION –surest sign that labor has begun with effective and productive uterine contraction - can be voluntary and come without any warning and can be alarming to the person UTEROTROPIN – agent that prepares the uterus and the cervix for labor - causes the uterus to become irritable and cervix to soften UTEROTONIN – agent cause uterine contraction ( Oxy, Prostaglandin) Characteristics: Intermittent – alternating contraction & relaxation/causes discomfort – labor pain Involuntary – not within the control of the parturient Regular Causes of pain during uterine contraction ischemic state of uterine muscle during uterine contraction/experience hypoxia of the contracted myometrium pressure on the nerve ganglia in the cervix & lower uterine segment by the presenting part/compression of the nerve ganglia in the cervix stretching of ligaments adjacent to the uterus in pelvic joints stretching and displacement of the tissues of the vulva and perineum Uterotropin – agents that prepares the uterus & cervix for labor - cause the uterus to become irritable & cervix to soften Uterotonin – agent that cause uterine contraction Ex. Oxytocin, prostaglandin Phases of Uterine Contraction a. Increment/crescendo – first phase during which intensity of contraction increases (longest phase) 9|P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences b. Acme/apex - known as the height of contraction/peak of contraction c. Decrement/decrescendo - last phase in which uterine contraction decreases/muscle starts to relax Figure 19. Phases of Uterine Contraction. Retrieved from https://nursekey.com/uterine- contraction-palpation/ b. EFFACEMENT shortening and thinning of the cervical canal from 1-2 cm, the one in which no canal as distinct from the uterus exist it is expressed in percentage (%) refers to the cervical canal thinning and shortening of cervical canal from 25%-100% (100% - paper thin) c. DILATATION progress by which the cervix opens specifically referring to the external cervical os expressed in cm refers to the widening and opening of the cervix from 0-10 cm Causes of Dilatation pressure of both the presenting part and the rupture of the BOW result form uterine contraction Primis – effacement occur, dilatation occur Multis – dilatation proceeds effacement 10 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences d. UTERINE CHANGE – uterus is gradually differentiated into 2 distinct portion Upper uterine segment thick/ active to expel the fetus only part which contract the round ligaments of the uterus become tense during dilatation and expulsion, causing an abdominal indentation( a danger sign of labor signifying impending rupture of the uterus if obstruction is not relieved lower uterine segment become thin walled supple and passive – to accommodate the descending fetus and facilitates its expulsion (so that fetus can be pushed out easily) PHYSIOLOGIC RETRACTION RING - formed between the boundary of the upper and lower uterine segment - a ridge around the inside of the uterus that forms during the second stage of normal labor at the junction of the thinned lower uterine segment and thickened upper segment. It forms as a result of progressive lengthening of the muscle fibers of the lower segment and concomitant shortening of the muscle fibers of the upper segment Figure 20. The Physiologic Retraction Ring. Retrieved from https://obgynkey.com/physiology-of-labor/ BAND’LS PATHOLOGIC RETRACTION RING - seen in difficult labor when fetus is no larger than the birth canal - It is the rising up retraction ring during obstructed labour due to marked retraction and thickening of the upper uterine segment while the relatively passive lower segment is markedly stretched and thinned to accommodate the foetus - is seen and felt abdominally as a transverse groove that may rise to or above the umbilicus 11 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences C. COMPARISON BETWEEN TRUE AND FALSE LABOR PAIN TRUE LABOR 1. Contraction increases in frequency, intensity and duration and occur at regular interval 2. progressive cervical changes 3. blood show 4. progressive fetal descent 5. walking intensify contraction 6. discomfort begins in the back then radiates to abdomen 7. sedation does not stop contraction FALSE LABOR 1. irregular inefficient contraction not causing the progressive changes associated with true labor 2. no cervical change 3. no blood show 4. discomfort in abdomen may be relieved by walking 5. sedation tends to decrease the number of contractions Table 5. Difference Between True Labor and False Labor True labor False Labor Contraction 1. regular as it progresses Irregular st 2. 1 felt in lower back and sweep Generally confined in the abdomen around to the abdomen in a girdle like fashion 3. increase in frequency, duration, Without increase in frequency, duration and intensity and intensity Activity 4. contraction is nor relieved by any Often disappear with ambulation activity Cervical Changes 5. accompanied by cervical Absent cervical changes effacement and dilatation 12 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Table 6. LENGTH OF NORMAL LABOR STAGE OF LABOR PRIMIS MULTIS 1st stage(Dilatation/Cervical Stage)- begins w/ true labor until complete 12 ½ hours 7 and 20 minutes effacement & dilatation a. latent 8½ 5½ b. active 4 2 c. transition 1 10-15 minutes 2nd stage-from dilatation to delivery of 80 minutes (average: 50- 30 min. (average: 20- the baby 60 minutes) 30 minutes) 3rd stage-from delivery of the baby to 10 minutes (average: 5- 10 minutes (average: delivery of placenta 30 minutes) 5-10 minutes) 4th stage (Recovery stage) 1-2 hours TOTAL= 14 HOURS TOTAL = 8 hours Activity 1. Application of Signs of Labor You have learned about the signs of labor. Now, it’s time for you to apply what you’ve learned. Fill-up the box by putting the corresponding information. Factor True Labor False Labor Contractions Show Cervix Fetal Movement 13 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Wrap-up-activity: After this part, can you now classify the different signs of labor and differentiate the accordingly? Post-Assessment You will be given a quiz for the Lessons 1-2. Please wait for the schedule of the evaluation quiz. References: Pillitteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing family. LESSON 3. COMPONENTS OF LABOR AND DELIVERY A successful labor depends on five integrated concepts. All of these components of the history should be obtained, even if they already were obtained and documented during the prenatal period. Learning Outcomes: After mastering the concepts of this lesson, you must have: 1. Described the components of labor. 2. Determined the effects of the components to the labor process. Warm-up-activity: What are the 5 Ps of labor? 1. P- 2.P- 3.P- 4.P- 5.P- 14 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 1. POWER – forces acting to expel the fetus (a-b) a. PRIMARY POWER – uterine contraction - Abdominal & uterine muscles - Supplied by the fundus of the uterus Purposes: propels presenting part downward/forward effacement of the cervix dilatation of the cervix Effects of Contractions: increase maternal BP – due to the increase peripheral arterial pressure NOTE: check BP in between contraction Decreases blood flow to the uterus- prolonged can cause fetal hypoxia Cervical dilatation Contraction with pushing/bearing down expels the fetus and placenta during the 2nd and 3rd stages of labor PHASES OF CONTRACTION 1. Increment/cresendo- contraction is starting and intensity starts to build up (longest phase) 2. Acme/apex- peak of contraction 3. Decrement/decresendo- muscles start to relax Uterine Contraction Duration interval A B C D frequency CHARACTERISTICS OF UTERINE CONTRACTION DURATION – how long (from A-B) From onset to last phase Maximum duration = 90 sec normal Found during transition phase and 2nd stage FREQUENCY – how often (from A-C) 15 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Period from beginning of the 1st contraction to the beginning of the next contraction refers to the rate at which contractions are occurring INTERVAL – (from B-C) From last phase of contraction and beginning of the next Time for maternal sleep and relaxation INTENSITY – can be determined by placing lightly on the fundus with fingers spread - refers to the strength of uterine contraction TYPES: 1. Mild Contraction - slightly tense fundus that is easy to indent with fingertips 2. Moderate Contraction - firm fundus that is difficult to indent fingertips 3. Strong Contraction - rigid board like fundus that is almost impossible to indent with fingertips UTERINE CHANGES OCCURING DURING UTERINE CONTRACTION a. Upper segment – thicker and shorter - thick/active to expel the fetus - only part that contracts b. Lower segment – thinner and longer (these are reverse, ineffective contractions and they may actually cause tightening rather than dilatation of the cervix - passive PHYSIOLOGIC RETRACTION RING- formed between the upper and lower segment of the uterus. BANDL’S PATHOLOGIC RETRACTION RING- seen in difficult labor when fetus is bigger than the passageway – a physiologic retraction ring - a thickened ridge of uterine musculature between upper and lower uterine segment - danger sign of labor signifying rupture of the uterus when not treated b. SECONDARY POWER – Bearing down effort of the mother 16 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences This is the mother voluntary expulsion effort Working forces - abdominal muscle - diaphragm 2. POSITION mothers position affects the anatomic and physiologic adaptation to labor cardiac output normally increase during labor as uterus contracts standing walking ↑ uterine contraction stronger and more efficient & average of squatting labor is shortened ADVANTAGES Frequent change in position will: relieve fatigue improve circulation to body parts Squatting – during the second stage moves the uterus forward, thereby strengthening the long axis of the birth canal Sitting position- abdominal muscle work in greater synchrony with uterine contraction during bearing down effort 3. PERSON ITSELF/PSYCHOLOGICAL RESPONSE - the attitude of the mother during labor greatly affects labor process and outcome 1. Pregnancy woman general behavior has an influence to the progress of labor Factors Affecting Psychological Response a. cultural influence/perception about labor and delivery (beliefs and practices) EX. not to sit stairs during labor- unable to deliver b. response to uterine contraction c. childbirth class – Lamaze method d. previous experiences/past experiences e. ability to communicate feelings to significant others – support system 17 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 2. Relaxation, awareness and participation in labor result to less intense and shorter labor – Kegel’s – less intense, shorter labor 3. Causes of labor pains a.traction on the perineum b. uterine contraction c. emotional tension d. hypoxia of contracted myometrium e.pressure/compression of nerve ganglia into the cervix f. stretching of cervix during dilatation g. stretching of peritoneum overlying the uterus h. stretching of the ligaments 4. PASSENGER – FETUS/FETAL MEMBRANE even if an adequate size pelvis, if fetus is too large and difficult position would be difficult to deliver the passenger Assessment: A. FETAL HEAD/FETAL SKULL from an obstetrical point of view the FETAL SKULL is the most important part of the fetus because during birth process it is: a. largest part of the body b. most frequent presenting part c. least compressible of all parts HEAD – wider than the shoulder - make up approx - imately 1 quarter ¼ of the Bb length - 96% of Bb are born head first CRANIAL BONES COMPOSED OF 7 BONES 1. Parietal bones 2 pairs of bones forming top and sides of cranium 2. Frontal bones 2 pairs – forming forehead and upper part of the orbit 3. Temporal Bones 2 pairs – forms side of the cranium 4. Occipital Bones 1- saucer shaped that forms back and part of the base of the cranium Others: 1. Sphenoid 2. ethmoid 18 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Frontal, Parietal Occipital bones are the MOST impt. Fetal skull-bec they form presenting part when the fetus is in cephalic presentation AREAS OF SKULL/LANDMARK OF THE FETAL SKULL 1. Occiput –back of head, area over the occipital- posterior fontanel 2. Vertex- top/area between ant. and pos, fontanel 3. Bregma anterior front/ junction of coronal/sagittal – diamond shaped, large anterior fontanel 4. Sinciput - brow, eyebrow, forehead part - Area over the frontal bone to anterior fontanel 1. SUTURE important coz they allow the bones to move, overlap and change in shape – to fit the birth canal (molding or overlapping of cranial bones inorder to reduce the size of fetal head during delivery) the spaces between bones line of junction or closure between bones membranous spaces between cranial bones it also gives allowance for further brain development MAIN SUTURES: a. frontal – between 2 frontal bones b. coronal – between frontal and parietal c. sagittal – between two parietal bones/divides the skull into left and right d. lamboidal – between parietal and occipital bones MOLDING – process of changing the shape of the fetal head in order to fit through birth canal - no molding occurs if it is breech - shaping of the fetal head by overlapping of the cranial nerve to facilitate movement through the birth canal during labor 2. FONTANELES – “little fountains” they pulsate areas where 2 or more suture meet membrane covered spaces at the junction of the main suture line A. ANTERIOR FONTANEL – bregma formed by 2 frontal and 2 parietal bone 19 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences larger, diamond shaped close between 12-18 months of age measures 2.5 cm x 2.5 cm *formed by the intersection of the sagittal, frontal & coronal suture B.POSTERIOR FONTANEL/Lambda formed by union of parietal and occipital bones formed junction with sagittal and lambdoidal suture triangular shape, small close in 6-8 weeks or 2-3 months formed by the intersection of the sagittal, frontal and coronal suture MEASUREMENTS of fetal head: the shape of the fetal skull causes it to be wider in its antero posterior (AP - front to back) in its transverse diameter – side to side to fit the birth canal, the fetus must present the smallest diameter to the smaller diameter of the maternal pelvis 1. TRANSVERSE DIAMETER OF FETAL SKULL Biparietal – 9.5 cm – most important diameter represent greatest width that must be presented in the pelvic inlet - The most important transverse diameter because it is the greatest diameter that must be presented to the pelvic inlet’s AP diameter and at the outlet transverse diameter. Bitemporal – 8 cm Bimastoid – 7 cm 2. ANTERO POSTERIOR DIAMETER SUB-OCCIPITO BREGMATIC (top of skull) from the inferior aspect of the occiput –to the ant. center of the Fontanel narrowest/smallest AP diameter of fetal head when the fetus is flexed fully 9.5 cm average measurement OCCIPITO FRONTAL DIAMETER Diameter presented when head is extended and the presenting part is the face 12 cm average, measure from the bridge of the nose to occipital prominence. 20 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences OCCIPITO MENTAL DIAMETER - The diameter presented when the head is extended and the presenting part is the face from occiput – chin when the head is extended presenting part is face measure from chin to posterior fontanel. it is the widest 12.5 – 13.5 cm. *circumference of fetal head >Sub-occipito bregmatic – 33 cm >occipitofrontal – 35 cm >mentovertical – 39 cm B. FETAL LIE – relationship between long axis of the fetus to the long axis of the mother (spine) TYPES: a. VERTICAL/LONGITUDINAL LIE long axis of the fetus is parallel to long axis of the mother approximately 99% fetus assume this fetal lie the fetus is lying lengthwise in the mothers abdomen CLASSIFICATION 1. CEPHALIC LIE = head is the presenting part 2. BREECH LIE= buttocks is the presenting part b. HORIZONTAL/TRANSVERSE LIE the fetal axis cross the maternal axis such as they are perpendicular to one another long axis of the fetus is perpendicular to the log axis of the mother shoulder presentation Causes of Transverse Lie 1. multiparity 2. contracted pelvis 3. placenta previa 21 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences C. FETAL ATTITUDE/FETAL HABIT relationship of fetal parts to each other the most striking character of the fetal habitus is flexion refers to the degree of flexion of the fetal body head and extremities a. good attitude/complete flexion/general flexion spinal column is bowed forward. The head is flexed forward, so that the chin touches the sternum, arms are flexed and folded on the chest , thighs are flexed onto the abdomen in the calves of the legs are pressed against the post aspect of the thigh SUBOCCIPITOBREGMATIC DIAMETER b. moderate flexion/military Fetus chin is not touching his/her chest OCCIPITO FRONTAL DIAMETER c. poor flexion Back is archer, neck is extended the fetus is in complete extension OCCIPITOMENTAL DIAMETER (face presentation) D. FETAL PRESENTATION Position of the fetus that enters the pelvis and covers the internal os of the cervix/ it is part felt on internal examination Determined by fetal lie and attitude First part to come out during delivery TYPES (3): 1. CEPHALIC – most frequent and accounts 95% - when the head comes out first because the part that first contacts the cervix a. vertex/ occiput – most common and ideal because the smallest diameter of the fetal head is the presenting part - the posterior fontanel is the presenting part *FHT are best heard at the area of the fetal back and located at either RLQ/LLQ b. brow – moderate flexion of the head - occipitomental diameter (12.5 cm) is presented for delivery c. Face - head well extended and face is the presenting part ( edema and distortion of the face may occur) - possible complication is damage to cervical cord 22 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences d. sinciput – head moderately flexed, the anterior fontanel is the presenting part - occipitofrontal diameter (12.5 cm ) is presented for delivery - also called military position/attitude e. mentum/chin – head is hyperextend to present the chin, the widest diameter - fetus cannot enter the pelvis 2. BREECH PRESENTATION – 3% considered difficult delivery, the presenting part influences the degree of difficulty feet or buttocks is the presenting part 1. complete breech/full breech - feet and legs flexed on the thigh and the thighs are flexed on the abdomen 2. frank/inc. - hips flexed and legs extended, the legs touching the abdomen with the buttocks as the presenting part - most common type of breech 3. footling/single or double - one or both feet is the presenting part HAZARDS OF BREECH DELIVERY 1. intracranial hemorrhage- cause by unmolding 2. Cord compression 3. Abruptio placenta 4. ERB duchenne paralysis/brachial plexus injury - due to excessive traction of the shoulder 5. hip dislocation 6. fracture of the clavicle 3. SHOULDER PRESENTATION – 1% presenting part is usually the shoulder the fetus is lying perpendicular to the long axis of the mother and the shoulder is the presenting part vaginal delivery is not possible, CS is employed to effect delivery 23 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Causes: 1. relaxed abd. wall from grand multiparity that allow the uterus to be unsupported and fall forward 2. pelvic contraction in which there is more horizontal space than vertical space 3. placenta previa – located low in the uterus observing space may also limit the fetus ability to turn E. FETAL POSITION – the relationship of the denominator of the presenting part to the 4 quadrants of the mothers pelvis - important because it influences the process and efficiency of labor - relationship of the fetal presenting part to specific quadrant of the mother’s pelvis Quadrants of the woman’s pelvis: 1. R. ant. (right anterior side of the mother’s pelvis) 2. R. post. (right posterior) 3. L. ant (left anterior) 4. L. post. (left posterior) NOTE: Posterior positions result in more backache because of the pressure of the fetal presenting part on the maternal sacrum POINT OF DIRECTION/FETAL REFERENCE PT. DENOMINATOR – refers to the lowest portion of the presenting part 1. vertex - occiput 2. face - chin 3. breech - sacrum 4. shoulder –scapula/ acromion process - various position are expressed in abbreviation made up to 1 st letter of each word which describes the position 1. 1st letter – defines whether that landmark pointing to the mother R/L 2. middle letter – denotes fetal landmark O – occiput – vertex presentation F - fronto M – mentum - face Sa, M – sacrum - breech A or Sc– acromium/scapula – shoulder presentation 3. last letter – defines whether the landmark points ant. (A) post (P) or 24 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences transverse (Y) in the middle-T VERTEX – LOA, LOP, ROA, ROP, ROT ROA/LOA – most common and favorable position at birth (40 %) ROP/LOP – fetal occiput is on maternal L side and toward back face is up toward L abdomen (12 %) Occipito – posterior position (abnormal) LOA – 3 % ROP – 10 % *Each presenting part has the possibility of six positions. They are normally recognized for each position--using "occiput" as the reference point. 1. Left occiput anterior (LOA). 4. Right occiput anterior (ROA). 2. Left occiput posterior (LOP). 5. Right occiput posterior (ROP). 3. Left occiput transverse (LOT). 6. Right occiput transverse (ROT). *A transverse position does not use a first letter and is not the same as a transverse lie or presentation. 1. Occiput at sacrum (O.S.) or occiput at posterior (O.P.). 2. Occiput at pubis (O.P.) or occiput at anterior (O.A.). NURSING CARE – side lying, backrub counter sacral pressure BREECH LSA (Left sacro anterior) RSA (Right sacro anterior) LSP (Left sacro posterior) RSP (Right sacro posterior) LST (Left sacro transverse) RST (Right sacro transverse) FACE LMA (Left mento anterior) RMA (Right mento anterior) LMP (Left mento posterior) RMP (Right mento posterior) LMT (Left mento transverse) RMT (Right mento transverse) SHOULDER LADA (Left acromio dorso anterior) LADP (Left acromio dorso posterior) RADA (Right acromio dorso anterior) RADP (Right acromio dorso posterior) F. FETAL STATION – refers to the relationship of presenting part of the fetus to the ischial spines of the mother 25 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences LAND MARK – ischial spines A. FLOATING OR HIGH B. STATION 0 C. STATION -1 TO -4 D. STATION +1 E. STATION +3 to +4 Minus station (-) – presenting part is above the ischial spine Zero station (0) – pp at the level of the ischial spine Positive station (+) – pp is below the ischial spine B. PLACENTA- placental separation occurs automatically as uterus contracts PLACENTA - formed from chorionic villi and decidua basalis - it reaches maturity at 12 weeks gestation and continue to function effectively until 40th-41st weeks. It begins to degenerate after 42nd week making it dangerous for the fetus to remain utero beyond 42 weeks gestation Function: produces embryo’s nourishment, eliminates waste & exchange respiratory gases Weight – 500 gms at term - occupies about ¼ of the uterine cavity - composed of 15-20 cotyledons Assessment: 1. TYPES OF PLACENTAL DELIVERY: a. SCHULTZ MECHANISM – 80% - shiny, clean,fetal side - separate from center to edges - folds itself like an umbrella shape - delivered with shiny, ,bluish, clean looking fetal surface first with placental detachment starting from the center b. DUNCAN – 20% - dirty, maternal surface - separate edges to center - rough, reddish dirty looking maternal surface 26 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 2. ASSESS maternal side of placenta/inspect (a-c) a. first remove blood clots from maternal side into the container - determine accurate of blood loss b. determine the health of the maternal side - normal – dark, bluish red color and firm in consistency c. determine the completeness of cotyledons - 15 to 20 if laid flat on a surface they will fit together 3. ASSESS fetal side of the placenta a. check the fetal side for INSERTION (usually centered) NOTE: If the cord is maternally attached it is BATTLEDORE PLACENTA b.measure its length 1. normal – 55 – 60cm 2. short cord – less than 40 cm - can be a factor a. uterine inversion b. abruption placenta – as traction is exerted onto the cord every time the fetus moves owing to inadequate allowances for moving 3. long cord – can be a factor for cord prolapsed/nuchal cord 4. CHECK for the pressure of infarct – which are reddish in early stage and later becomes whitish areas about 2.5 cm in diameter Infarct – localized area of necrosis in a tissue resulting from anoxia - ↓ blood supply to area - Areas of necrosed chorionic villi 5. CHECK for the presence of 3 blood vessels (AVA) esp. renal disorders - incomplete blood vessels associated with GUT problems particularly renal disorders 6. MEASURE/WEIGH PLACENTA a. measurement – 20cm in diameter, 1 inch in thickness b. weight – 400 -500grams or 1/6 of the baby at term 7. DETECT abnormalities a. unhealthy – soft and muschy maternal side 27 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences b. meconium-stained – greenish membrane and cord - means that fetus possibly inhaled meconium which lead to pulmonary complications (meconium aspiration syndrome) TYPES OF ABNORMAL PLACENTA (7) 1. Placenta Succenturiata - has an accessory lobe of placental tissue in the fetal sac with blood vessels running to the main placenta - most significant abnormalities as the extra lobe can be retained in the utero causing profuse postpartal bleeding 2. Placenta Circumvallata - with double layer of amnion and chorion which undergone infarction 3. Placenta Bipartita - has two complete or almost complete lobe 4. Placenta Tripartita - has 3 complete or almost complete lobe 5. Battledore Placenta - cord is situated at the very edge of the placenta 6. Edema of the Placenta - large and pale placenta with water oozing from it - associated with hydrops fetalis – most serious form of hemolytic disease of the newborn complication – Rh incompatability 7. Placenta velamentosa - the cord is inserted into the membrane of the fetal sac 5-10cm from the edge of the placenta, with umbilical blood vessels running between placenta and cord C. FETAL MEMBRANE/PLACENTAL MEMBRANE a. amount of chorion/thicker membrane near the maternal side and helps form the placenta; it should be sufficient to have contain the fetus and amniotic fluid 28 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences b. amnion (thinner membrane nearer to the fetal side that secrete amniotic fluid can be pulled from chorion up to the cord) 5. PASSAGEWAY - pelvis Components: a. bony pelvis – resemblance to a basin - evaluated during the 1st prenatal visit and repeated during the 3rd trimester which is more accurate coz’ relaxation of pelvis joint and ligaments. The true pelvis is that which lies below the pelvic brim and is a confined space thru which the fetus must pass. *To negotiate with birth canal fetal head must undergo series of passive movement FEMALE PELVIS - composed of 4 bones Functions: 1. provide protection to organs found in the pelvic cavity\ 2. provide attachment to muscles 3. support uterus during pregnancy 4. serves as birth canal Types (4): 1. Gynecoid – normal female pelvis, circular in shape, ideal for child bearing 2. Android – male pelvis, heart shape, usually result to difficult delivery 3. Anthropoid – ape like pelvis, oval shape w/ AP wider than transverse 4. Platypelloid – flat shape, transverse diameter is wider than AP diameter - Shallow AP diameter may not allow the fetal head to rotate 1. 2 innominate bones/hip bones - form the anterior and lateral aspect of the pelvis Consist of : a. ilium - largest bone of the pelvis The upper curve is the ILIAC CREST that forms the hip bone 29 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences b. ischium - lowest part with large prominences the ISCHIAL TUBEROSITY- which the body rest in sitting position c. OS pubis -front portion consist of superior and anterior ramus 2. sacrum – wedge shape/triangular shaped bone forming the posterior portion of the pelvis - back port of the pelvis with 5 sacral vertebrae SACRAL PROMONTORY- center of the upper surface of the 1st sacral vertebrae. 3. coccyx –small bone consisting of 4 coccygeal vertebrae fused together. - mobility of the sacrococygeal joint allow fetal head deliver in labor. DIVISIONS (3): 1. FALSE PELVIS – upper large division that supports the uterus in the abdominal cavity during pregnancy, the portion above the linea terminalis (LT) - superior half - vary in size among women but no significance. 2.TRUE PELVIS – lower, smaller portion , important in childbearing, lies below LT - inferior half - the canal thru which the baby must pass 3 PARTS: TP=true pelvis TD = 13.5 cm APD = 11 cm a. INLET / brim – fetus must first enter – upper boarder of the true pelvis b. OUTLET – front symphysis pubis and pubic arch – lower boarder c. CAVITY – space between outlet upper and lower, cervical canal w/ longer posterior than anterior wall 3. LINEA TERMINALIS- imaginary line that separate the true from the false pelvis. ARTICULATION: connections between the bones of the pelvis involving 4 groups of ligaments 1. SACROILIAC JOINT - irregular synovial joint between sacrum and ileum 2. SACROCOCYGEAL JOINT – connects the sacrum and coccyx 3. SYMPHYSIS PUBIS – line of union of union esp. cartilaginous joint in which adjacent bony surfaces are firmly united by fibrocartilage 30 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences IMPORTANT. PELVIC DIAMETER/ measurement 1. INLET – pelvic brim, fetus 1st enter (a-d) a. True Conjugate/ conjugate vera – from middle of the sacral promontory (SP) to the middle pubic crest - ant post diameter - distance between the upper superior border of the symphisis pubis to the sacral promontory - measured actually by x ray. - ADEQUATE size – 11- 11.5 cm or more 13.5 cm - from middle of S.Promontory to the middle of pubic crest b. obstetrical conjugate – from middle of sacral promontory to an area approximately 1 cm below the pubic crest - ant post diameter - shortest ant post diameter thru which the head must pass - distance bet the inner surface of symphysis pubis to sacral promontory. - cannot be measured directly by examining finger NORMAL – 10 cm - the size of the diameter determine whether the fetus can move down into the birth canal in order for engagement to occur c. oblique diameter - from sacroiliac to ileo pectineal eminence on the opposite side of the pelvis. ADEQUATE SIZE- 12- 12.75 cm or just 13 cm. d. transverse diameter - widest diameter at inlet - 13 cm - helps determine the shape of the inlet 2. OUTLET- bordered by 2 ischial tuberosities a. Diagonal conjugate – from suprapubic angle to the middle of the SP - widest ant diameter - distance from lower inf margin of the symphysis pubis to sacral promontory. - ADEQUATE SIZE- 12.5 cm or more - Estimated by vaginal pelvic exam b. transverse diameter 31 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences - distance bet ischial tuberosities - narrowest diameter of the outlet - ADEQUATE size 9- 11 cm - Measured by pelvic exam c. post sagittal - extend from tip of sacrum to a R angle inter section with the line bet the ischial tuberosities - NORMAL size 7.5 cm more X RAY PELVIMETRY – to determine pelvic size in certain clinical circumstances PURPOSES : to determine safety of vaginal delivery for breech presentation to evaluate women with history of previous injuries that affect the bony pelvis Activity 1. Rosana Basil was a multipara mother, she was certain her labor was not normal because it had lasted for 6 hours. Is this an unusually long time for a first stage of labor? Do you think she would have been more comfortable knowing the usual length? Wrap-up-activity: Nurse provides physical and emotional support during the labor and birth process to assist a woman to achieve her goals. When a woman is admitted to the labor and birth area, the admitting nurse must assess and evaluate the risk status of this pregnancy and initiate appropriate interventions to provide optimal care for this client. What do you think is the most important component of labor? Is it possible for one component to be disregarded? Post-Assessment You will be given a quiz for the Lesson 3. Please wait for the schedule of the evaluation quiz. References: Pillitteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing family. 32 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Lesson 4. NURSING PROCESS OVERVIEW FOR THE WOMAN IN LABOR OF LABOR HEO THEORIES OF LABOR RIES OF LABOR Assessment of a woman in labor must be done quickly yet thoroughly and gently. A woman is keenly aware of words spoken around her and the manner with which procedures are carried out. Remember that pain is a subjective symptom. Only the woman can evaluate how much she is experiencing or how much she wants to endure. Assess how much discomfort a woman in labor is having, not only by what she scores on a pain scale but also by subtle signs of pain such as facial tenseness, flushing or paleness of the face, hands clenched in a fist, rapid breathing, or rapid pulse rate. Knowing the extent of a woman’s discomfort helps guide the choice of comfort interventions she may need. When establishing expected outcomes for a woman in labor and her partner, be certain they are realistic. Because labor usually takes place over a relatively short timeframe (average, 12 hours), outcomes must be met within this period. On the other hand, it is important not to project a definite time limit for labor to be completed, because the length of labor can vary from woman to woman and still be within normal limits. Be certain to incorporate both the woman and her support person in planning, so that the experience is a shared one. Comfort promotion is a vital part of care. A plan that addresses the discomforts of labor includes planning for education, validation, and response to a woman’s pain to help her maintain realistic perceptions about it. Interventions in labor must always be carried out between contractions if possible, so that a woman is free to use a prepared childbirth technique to limit the discomfort of contractions. This calls for good coordination of care among health care providers and planning with the woman and her support person. The person a woman chooses to stay with her during childbirth can be a husband, the father of the child, a sister or parent, or a close friend. During labor, evaluation must be ongoing to preserve the safety of a woman and her new child. After birth, evaluation helps to determine a woman’s opinion of her experience with labor and birth. 33 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Learning Outcomes: After mastering the concepts of this lesson, you must have: 1. Assess the degree and type of discomfort a woman is experiencing during labor and birth, including her ability to cope with it effectively. 2. Formulate nursing diagnoses related to the effect of pain or pain management during labor and birth. 3. Establish expected outcomes to meet the needs of a woman experiencing discomfort during labor and birth. 4. Plan nursing interventions to promote comfort during labor and birth such as teaching about relaxation or breathing exercises. 5. Implement common complementary and pharmacologic measures for pain management during labor and birth. 6. Evaluate expected outcomes for effectiveness and achievement of care. Warm-up-activity: (Adapted form Pillitteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing family) Celeste Bailey is a 26-year-old woman you admit to a birthing room. She has been having labor contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants to have her baby “naturally” without any analgesia or anesthesia. Her husband is in the Army and assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital, Celeste does not want her called. She asks if she can talk to her mother on the telephone instead. As you finish assessing contractions, she screams with pain and shouts, “I’m doing everything I’m supposed to do! How much longer does this go on?” What are your interventions for Celeste Bailey? STAGES OF LABOR A. FIRST STAGE / DILATATION begins with the true labor / uterine contraction until the cervix is completely effaced and dilated 2 important events that take place during the first stage of labor 34 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 1. cervical dilatation 2. effacement PHASES: I. LATENT PHASE –early time in labor 0-3 cm. cervical dilatation – minimal because effacement is occurring 15-30 sec. duration 10 min. frequency 5-10 min. interval with mild regular contraction – described like menstrual cramp MATERNAL BEHAVIOR LENGTH OF LATENT PHASE talkative 1. PRIMI- six (6 hrs) alert 2. MULTI- 4-5 hrs less anxious excited and happy – knowing end of pgy is near in control RESPONSE happy eager to be in labor need independence by taking care of own body needs GENERAL NURSING CARE 1. establish rapport 2. breathing technique – encourage 3. provide needed info – progress of labor 4. encourage participation 5 facilitate position of comfort 6. encourage ambulation – further descent of the fetus 7. offer ice chips 8. voiding 1-2 hrs – same with ambulation DISCOMFORT: backache, abdominal cramps NURSING CARE TO DISCOMFORT proper positioning- left side lying position back rub 35 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences support system (husband) – stay with the wife nurse should stay with pt. to provide support NURSING DIAGNOSIS anxiety ineffective breathing pattern pain knowledge deficit NURSING CARE 1. hospital admission – provide reassurance and privacy a.) personal data b.) OB data 2. assessment – general examination (IE, leopolds- to determine progress of labor) PRESENTATION: 1. breech 2. cephalic 3. monitoring and evaluation a. uterine contraction 1. duration (A-B) 2. interval (relaxation) will jeopardize the fetus (B-C) 3. frequency (A-C) 4. intensity b. BP- 120/80 mmHg should be taken midway between contraction taken q 1° or ½° * if with HEADACHE – initial nursing care check BP * if N – tension h/a * if E – s/s of toxemia c. FHT – 120-160 N taken midway between contraction if abnormal FHT – reposition the mother S/S OF FETAL DISTRESS 36 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences a.) bradycardia – FHT below 100/min. b.) tachycardia – FHT above 180/min. c.) meconium stained in non-breech d.) fetal trashing – hyperactivity of fetus as it struggle for more O2 4. Emotional support constantly informing her the progress of labor 5. health teaching a.) bath- advisable if contraction is still tolerable to make woman more comfortable b.) ambulation to help shorten the first stage of labor discourage if BOW is ruptured c.) NPO solid foods should be avoided because * digestion delayed during labor * full stomach interfere with proper bearing down * may vomit and can cause aspiration d.) enema – not routine PURPOSES OF DOING ENEMA 1.) full bowel hinder progress of labor 2.) expulsion of feces during 2nd stage predispose to infxn. 3.) full bowel predispose post partum discomfort 4. allows more room for the descend of the fetal head in the pelvis CONTRAINDICATION 1.) vaginal bleeding 2.) abnormal fetal pres. / position 3.) ruptured BOW 4.) crowning 5.) premature labor e.) encourage patient to void q 2-3 hrs.coz full bladder retard fetal descend lead to urinary stasis – UTI lead to trauma of bladder during delivery 37 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences f.) perineal prep done aseptically fr. Front to back – use 7 method or zigzag g.) perineal shave – to provide clean area for delivery clipping rather than shaving not routine – depend in the patient desire and midwife discretion. h.) encourage Sims position promote relaxation between contraction prevent continual pressure of the gravid uterus on IVC favor anterior rotation of fetal head i.) should not bear down or push unnecessary at first stage of labor coz it leads to unnecessary exhaustion leads to cervical edema – coz of repeated pounding of fetus to the pelvic floor j.) abdominal breathing to decrease tension and hyperventilation k.) administration of analgesic as ordered * dosage based on the patient weight, status of labor, size, stage of gestation 1. NARCOTIC- common used analgesic specifically DEMEROL EFFECT: 1. depress sensory position of cerebral cortex 2. it has sedative and antispasmodic effect THEREFORE, it cannot be given early in labor because: 1. it retards progress of uterine contraction (bec. It is an antispasmodic) 2. it can be given if delivery is only an hour away because it causes respiratory depression in the NB. 3. RULE OF THUMB: administered if cervical dilatation is already 6-8 cm. DOSAGE: 25-100 mg.-depending on body weight. 38 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences ( in 20 min. of pt. experience a sense of well being and euphoria) 2. NARCAN (narcotic antagonist) - to counteract the toxic effect of Demerol a.) assist in the administration regional anesthesia * preferred over any other form because: it does not enter maternal circulation and does not affect the fetus much patient is completely awake and aware of what is completely happening neither does it depress uterine tone thus optional uterine contraction is achieved. 3. XYLOCAINE – is the anesthetic of choice (vasodilation) NURSING CARE: 1.) NPO with IVF to prevent aspiration, dehydration, and exhaustion because glucose aids in proper function of the uterine muscle. 2.) BP monitored TYPES OF ANESTHESIA 1.) PARACERVICAL – transvaginal injection into either side of the cervix - in lithotomy position - coupled with local anesthetic result in “ painless childbirth” 2.) PUDENDAL – thru sacro spinos ligament into the post areolar tissue - to decrease perception of pain during 2nd stage - make pt. comfortable - in lithotomy position SE = ecchymotic area – purplish discoloration of the skin due to blood at SQ tissues 3.) LOW SPINAL 39 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences a.) epidural – injected at the lumbar level outside the dura mater b.) saddle block – 5th lumbar space - anesthesia on the parts of the body that comes in contact with saddle, perineum, upper thigh and lumbar pelvis. - in sitting/ lying position with back aligned - block nerves that transmit pain at 1st stage COMPLICATION: SPINAL H/A – due to the leakage of anesthetic into the CSF or injection of air at the time of needle insertion MANAGEMENT >increase fluid >position flat on bed 8-12° after delivery SE >hypotension >fetal bradycardia >decrease maternal respiration 6.) transfer to DR – very important pd. bet. 1st and 2nd bulging of perineum – sign that the baby is about to be born *multi – DR at 7-8 cm II. ACTIVE PHASE 4-8 cm dilatation 45-60 sec. duration 3-5 min. frequency 2-5 min. interval w/ moderate contraction MATERNAL BEHAVIOR less talkative more anxious expression of fear being alone fear of losing control restless 40 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences anxiety feeling of helplessness fatigue become more dependent GENERAL NURSING CARE 1. encourage to maintain breathing pattern ( Yankee Doodle respiration) 2. provide quiet environment ( decrease stimuli) 3. give reassurance- termination is very near, progress of labor is good 4. comfort measures ice chips DISCOMFORT: HYPERVENTILATION – due to direct effect of progesterone on respiratory center in the brain SIGN AND SYMPTOMS 1. pallor 2. dizziness 3. light headedness with tingling sensation in tips of fingers NURSING CARE FOR DISOMFORT 1. offer a paper bag where she can breath into or cupped hands 2. give drugs for comfort - best given during the active phase when cervix is about 4-6 cm. so not to affect fetus so much. 3. advise breathing and relaxation technique 4. psychological comfort (PREIST) P-raise R-eassure E-ncourage I- inform progress S-upport system T-touch NURSING CARE /PLANNING 1. admission procedures V/S Hx 2. assess V/S, BP, FHT, UC, show, cervical changes 41 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 3. void q 2-3hrs 4. maintain bedrest 5. reexercise breathing technique 6. apply external fetal monitor III.TRANSITION PHASE - the mood of the woman suddenly changes and the nature of contraction intensity - very important - fully dilated - 50-60 sec. duration - 2-3 min. frequency - 1-3 min. interval - 2-3 min. contraction - regular/ strong uterine contraction MATERNAL BEHAVIOR: panicky loss of control N/V Amnesia circumoral pallor – paleness of skin around the mouth increase show irritable Problems: Backache Leg trembling Pressure on bladder & rectum (urge to defecate) NURSING CARE: giving comfort measures sacral measure proper bearing down technique – push contraction emotional support CHARACTERISTIC OF PATIENT: 1. mood changes and nature of contraction intensify 2. marked by the sudden gush of amniotic fluid as the fetus push at the birth canal if the membrane is still intact 42 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences *amniotomy – should be done if spontaneous rupture does not occur - to prevent aspiration of the fetus from amniotic fluid when he makes different position - if station is (-) should not be done- lead to cord compression 3. show become prominent 4. uncontrollable urge to push – signs: distended neck vein, profuse perspiration 5. N/V - is a reflex reaction due to decrease in gastric motility and absorption ASSESSMENT: 1.) Progress Of Labor > status > dilatation 2.) Cervical changes 3.) maternal mood changes 4.) sign of N/V 5.) maternal/fetal vital sign 6.) breathing pattern 7.) urge to bear down contraction NURSING DIAGNOSIS: 1. ineffective breathing pattern 2. powerlessness 3. ineffective individual coping PLANNING: 1. give + support 2. accept behavior changes 3. promote breathing pattern 4. discourage pushing until cervix is dilated 5. monitor contraction 6. observe sign of delivery B. SECOND STAGE – EXPULSION - begins complete dilatation of the cervix and ends with the delivery of the baby MECHANISM OF LABOR: 1.) ENGAGEMENT / LIGHTENING / DROPPING - head passes the pelvic inlet - head fixed in the pelvic 43 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 2.) DESCENT - involves the entrance of the greatest biparietal diameter of the fetal head to the pelvic inlet - it is caused by pressure of amniotic fluid, pressure of fundus upon the breech, contraction of abdominal muscles, extension and strengthening of fetus. 3.) FLEXION - as the fetal head moves deeper into the pelvis, it meets resistance from either cervix, pelvic floor as walls of the pelvis. This causes to flex so that the chin is brought in close contact the chest. - flexion of the fetal head enables the smallest diameter of the head, suboccipito bregmatic diameter to be presented to the pelvis for delivery. 4.) INTERNAL ROTATION - when the head reach the level of the ischial spine, it rotates from transverse diameter to anteroposterior diameter so that its largest diameter is presented to the largest diameter of the outlet. This allows the head to pass through the outlet. 5.) EXTENSION - the forces of the uterine contraction pushing effort of the mother and the resistance of the pelvic floor cause the head to extent towards the vaginal opening as the head extend, the chin is lifted up and then it is born. 6.) EXTERNAL ROTATION/RESTITUTION - when the head comes out, the shoulder w/c enters the pelvis in transverse position turns into anteroposterior pos. diameter of the outlet and pass through the pelvis. The internal rotation of the shoulder brings a corresponding external rotation of the head. 7.) EXPULSION - when the head is born, the shoulder and the rest of the body, follows without much difficulty. - delivery of the rest of the body NURSING CARE: 1.)positioning in DR table - placed both legs at the same time at the stirrup (to prevent injury to the uterine ligament) 44 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 2.) instruct mother to pant not to push during crowning * panting- rapid shallow breathing PURPOSE: - to prevent rapid expulsion of the baby *deep and rapid – hyperventilation→respiratory alkalosis→CO2 3.) assist in episiotomy - incision in perineum to prevent laceration PURPOSE: 1. prevent laceration 2. prevent prolonged 2nd stage of labor especially HPN, fetal distress 3. prevent prolonged stretching of the muscles supporting its bladder and rectum 4. enlarge the outlet in breech pres TYPES: 1.) median – middle part toward anus 2.) mediolateral – midline directed away from the anus * Natural anesthesia is used in episiotomy because pressure of presenting parts enough to deaden the perineum or fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily blocked. 4.) Perform Modified Ritgent’s Maneuver while delivering the head. a. cover the anus with sterile towel and exert upward and forward pressure of the fetal chin and at the same time exerting gentle pressure on the head to prevent rapid expulsion as soon as crowning takes place. >support the perineum to prevent laceration but also favor flexion so that smaller diameter of fetal head is the one presented at birth canal. b. case the head out- immediately wipe the mouth and nose to remove secretion to establish airway *head should be delivered in between contractions c. After head delivered insert 2 fingers to vagina to check presence of cord around the neck 45 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences *If loose – slit it down the shoulder or over the head *If tight – clamp cord individually apart then cut in between d. as the head rotate, deliver the anterior shoulder by giving gentle downward push and then deliver the post shoulder by giving a gentle upward lift. e. while supporting the head and the neck deliver the rest of the body *Take note that exact time of delivery of the baby Ritgen’s Maneuver will: Slows down delivery of the head Lets the smallest diameter of the head to be born Facilitates extension of the head 5.) hold the NB below the level of mother’s vulva for 1 minute after delivery to a few minutes to encourage flow going to the baby ( prevent anemia in infancy - amount 50 – 100ml) 6.) wrap the baby with sterile diaper to keep him warm 7.) place to the mother’s abdomen – to promote uterine contraction 8.) don’t cut the cord until pulsation stop bec. 50-100 ml is still flowing that can help to prevent anemia in infancy. * after pulsation place 2 forceps then cut in between 9.) establish bonding – show body to mother - inform the sex and time of delivery then give the baby to circulating nurse 10.) latch in – initiate breastfeeding 12.) proper recording (time- medication, baby out, placenta out, findings) 13.) immediate newborn care NURSING DIAGNOSIS: 1. potential from injury 2. noncompliance related to exhaustion 3. knowledge deficit 4. fear 5. fluid volume deficit 6. pain 7. altered tissue perfusion ASSESSMENT OF SECOND STAGE 46 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 1. observe sign of delivery 2. check contraction every 2-3 min 3. evaluate vagina and perineum stretching and thinning 4. check increase bloody show 5. evaluate urge to push 6. check bulging of perineum 7. observe vaginal opening 8. observe presenting part 9. check crowning 10. observe birth of presenting part PLANNING / IMPLEMENTATION 1. transfer to DR – support leg 2. careful positioning 3. help mother to use handle to pull on as she bears down 4. clean vulva and perineum to prepare for delivery 5. auscultate FHT every 5 minutes 6. check BP and PR q 5 min. 7.administer O2 if FHT decrease 8. catheterization 9. note time of delivery C. THIRD STAGE (PLACENTAL STAGE) - begins with the delivery of baby and ends with the delivery of the placenta - occurs 5 -10 minutes after delivery not over 30 mins. Powers at work: strong uterine contraction to effect separation maternal pushing to effect final delivery PRINCIPLE OF PLACENTAL DELIVERY *watchful waiting – watch and wait Signs of Placental delivery 1. CALKIN’S SIGN – 1ST SIGN, uterus shape changes, becomes globular and firm, rising high to the level of the umbilicus 2. uterus become mobile/firm & globular rising to the level of umbilicus 3. gushing of blood from vagina 4. lengthening of the cord 47 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences Types: a. Schultz (80%) > Most common > Shiny/fetal side > Center to edge (inverted umbrella) > Amount of blood loss (300-500 ml N) b. Duncan (20%) > less common > dirty/maternal side > umbrella shape NURSING CARE: 1.) watch and wait for signs of placental delivery 2.) deliver the placenta with Brandt Andrew’s maneuver - winding the cord around the clamp until placenta is born then holding the placenta and rotating it gradually to ensure no membrane is retained 3.) note time of placental delivery - should be 20- 30 min after the delivery of the baby otherwise to be referred “ stat” because this can cause severe bleeding 4.) inspect completeness ( abt. 15-20) cotyledons *retained causes bleeding *1st nursing measure after placental delivery 5.) determine the contraction by palpating the uterus - if relaxed, boggy, non palpable * 1st nursing action - massage - ice cap 6.) Assess perineum for laceration - should be firm following delivery and bright red blood coming from vagina - spouts of blood - laceration CATEGORIES: 1. 1st degree – vaginal mucosa + perineal skin 2. 2nd degree – VM + ps+ muscle 3. 3rd degree – vm+ ps+ m+ extension of the rectum 4. 4th degree – vm+ps+m+ extension muscle of the rectum + muscus membrane of the rectum 48 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 7. assist in episiorrhapy - if with vaginal pack – to maintain pressure in the suture line to prevent further bleeding (it has to be removed 24 - 48° post partum) 8.) establish bonding 9.) give perineal care, apply clean napkin 10.) remove legs from stirrup slowlY 11.) position flat on bed - prevent dizziness due to decrease intra abdominal pressure 12.) provide comfort * chill – provide blanket 13.) give initial nourishment 14.) allow pt. to sleep - to regain lost energy 15.) transporting to ward 16.) final charting D.) FOURTH STAGE (RECOVERY STAGE) 1st 1- 2 hrs. post partum said to be dangerous stage for the mother coz her v/s are still unstable potential crisis with increase incidence of hemorrhage urinary retention hypotension- side effect of anesthesia NURSING CARE: 1.) check v/s in 15 minutes till stable 2.) assess: a. fundus should be firm in midline if relaxed (massage) 49 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences b. lochia should be moderate in amount full bladder evidenced of fundus displacement some clots are expressed c. perineum should be clean and intact check if tender, edematous e. check episiotomy or laceration site from hematoma, bleeding or edema * management: apply ice pack to perineum immediately after delivery to decrease edema 3.) promote comfort keep warm give partial bath, perineal care change wet linen give ice cap for relief and analgesics as ordered 4.) rooming – in – concept- eye to eye contact to provide opportunity for positive relationship between parent and NB 5.) establish lactation if decided not to BF or contraindicated give suppressing to prevent BM production 6.) give health teachings 7.) continue providing comfort ASSESSMENT: 1. observe s/s placental separation discord – globular displacement of the uterus upward lengthening of the cord sudden gush of blood 2. observe placental expulsion Schultz Duncan 3. check for placental fragment 50 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 4. assess mother and baby in 15 minutes NURSING DIAGNOSIS: 1. pain 2. potential for fluid volume deficit 3. increase risk from altered parent’s 4. self care deficit PLANNING/IMPLEMENTATION 1. monitor NB status and begin bonding 2. monitor S/S of placental separation 3. inspect placental fragments 4. palpate fundus 1 minute after delivery and placement 5. massage uterus if not firm 6. observe lochia ( color amount) 7. inspect perineum 8. assist maternal hygiene – clean gowns, pads 9. administer oxytocin EVALUATION: 1. placental delivery with complication 2. minimal blood flow 3. mother tolerated procedure well, maternal uterus firm and contraction 4. documentation NEWBORN/ NEONATE - 1st 28 day of life IMMEDIATE CARE OF THE NEWBORN IN THE DELIVERY ROOM  ImmEdiate drying(1t step)  SkIn to skin contact(2nd step))  Properly-timed Cord clamping(3rd step)  Non-separation of mother and newborn (4th step) 1.) maintain appropriate body temp. no enough subcutaneous fat to keep him warm and does not know how to shiver measures to maintain appropriate body heat 1. dry immediately 51 | P a g e  MARIANO MARCOS STATE UNIVERSITY College of Health Sciences 2. wrap warmly 3. put under droplight 2.) assess the newborn carefully a. APGAR SCORE – standardized evaluation of the NB done after 1 and 5 minutes of life - to determine how well the NB is adjusting to extra uterine life 0 1 2 1 heart rate Absent Decrease 100 Increase 100 2. respiratory effort Absent Weak cry, slow Good strong cry 3. muscle tone Flacoid weak, soft Some flexion of Well flexed flabby ext. 4. reflex irritability No response Grimace weak cry Sneeze strong cry 5. color Pale blue Body pink, exp. Pink oil over blue Most critical observation in HR Color is least important score of O indicates no resp. distress score between 4-6 means moderately depressed score between 7-10 means severely depressed b. SILVERMANN ANDERSON- to evaluate degree of respiratory distress - Used to evaluate the respiratory status / breathing performance of premature infants and of newborns with respiratory distress 0 1 2 Chest Movement Synchronized Lag on Respiration See-saw respiration Intercoastal None Just visible Marked retraction Xiphoid retraction None Just visible Marked Nares dilatation None Minimal Marked Respiratory grunt None Audible by Audible by ear ste